2011 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Gundersen Lutheran Sr. Pref. Elite (no RX) (HMO) | ||||
Location: | Grant, Wisconsin Click to see other locations | ||||
Plan ID: | H5262 - 005 - 0 Click to see other plans | ||||
Member Services: | 1-800-394-5566 TTY users 1-800-947-3529 | ||||
— This plan information is for research purposes only. — Click here to see plans for the current plan year | |||||
Medicare Contact Information: | Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance |
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Email a copy of the Gundersen Lutheran Sr. Pref. Elite (no RX) (HMO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $95.00 (see Plan Premium Details below) | ||||
Annual Deductible: | no drug coverage | ||||
Health Plan Type: | Local HMO * | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $2,500 | ||||
Number of Members enrolled in this plan in (H5262 - 005): | 3,391 members | ||||
— Plan Premium Details — | |||||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $0.00 | $0.00 | $0.00 | $0.00 | |
— Plan Health Benefits — | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
$95.00 monthly plan premium in addition to your monthly Medicare Part B premium. | |||||
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. | |||||
This plan covers all Medicare-covered preventive services with zero cost sharing. | |||||
$2 500 out-of-pocket limit. | |||||
All plan services included. | |||||
** Doctor and Hospital Choice ** | |||||
Doctor and Hospital Choice | |||||
You must go to network doctors specialists and hospitals. | |||||
No referral required for network doctors specialists and hospitals. | |||||
** Extra Benefits ** | |||||
Prescription Drugs | |||||
Most drugs not covered. | |||||
$0 copay for Part B-covered drugs. | |||||
This plan does not offer prescription drug coverage. | |||||
Physical Exams | |||||
$0 copay for routine exams. | |||||
Limited to 1 exam(s) every year. | |||||
Separate Office Visit cost sharing of $15 may apply. | |||||
Vision Services | |||||
$0 copay for
| |||||
$300 plan coverage limit for eye wear every year. | |||||
Plan offers additional vision benefits. | |||||
Dental Services | |||||
In general preventive dental benefits (such as cleaning) not covered. | |||||
$15 copay for Medicare-covered dental benefits. | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
$95.00 monthly plan premium in addition to your monthly Medicare Part B premium. | |||||
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. | |||||
This plan covers all Medicare-covered preventive services with zero cost sharing. | |||||
$2 500 out-of-pocket limit. | |||||
All plan services included. | |||||
Doctor and Hospital Choice | |||||
You must go to network doctors specialists and hospitals. | |||||
No referral required for network doctors specialists and hospitals. | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care (Acute) | |||||
No limit to the number of days covered by the plan each benefit period. | |||||
$0 copay | |||||
Inpatient Mental Health Care | |||||
Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days. | |||||
$0 copay | |||||
Skilled Nursing Facility (SNF) | |||||
Authorization rules may apply. | |||||
Plan covers up to 100 days each benefit period | |||||
No prior hospital stay is required. | |||||
For SNF stays: | |||||
Days 1 - 20: 10% of the cost per day | |||||
Days 21 - 100: 0% of the cost per day | |||||
Home Health Care | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered home health visits. | |||||
Hospice | |||||
You must get care from a Medicare-certified hospice. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
See 'Welcome to Medicare; and Annual Wellness Visit' for more information. | |||||
$15 copay for each primary care doctor visit for Medicare-covered benefits. | |||||
$15 copay for each in-area network urgent care Medicare-covered visit. | |||||
$15 copay for each specialist visit for Medicare-covered benefits. | |||||
Chiropractic Services | |||||
$15 copay for each Medicare-covered visit. | |||||
$15 copay for each routine visit. | |||||
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers. | |||||
Podiatry Services | |||||
$15 copay for each Medicare-covered visit. | |||||
Medicare-covered podiatry benefits are for medically-necessary foot care. | |||||
Outpatient Mental Health Care | |||||
$15 copay for each Medicare-covered individual or group therapy visit. | |||||
Outpatient Substance Abuse Care | |||||
$15 copay for Medicare-covered individual or group visits. | |||||
Outpatient Hospital Services | |||||
$0 copay for each Medicare-covered ambulatory surgical center visit. | |||||
$0 copay for each Medicare-covered outpatient hospital facility visit. | |||||
Emergency Care | |||||
$50 copay for Medicare-covered emergency room visits. | |||||
Worldwide coverage. | |||||
If you are admitted to the hospital within 3-day(s) for the same condition you pay $0 for the emergency room visit | |||||
Outpatient Rehabilitation Services | |||||
$15 copay for Medicare-covered Occupational Therapy visits. | |||||
$15 copay for Medicare-covered Physical and/or Speech and Language Therapy visits. | |||||
$10 copay for Medicare-covered Cardiac Rehab services. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
10% of the cost for Medicare-covered items. | |||||
Prosthetic Devices | |||||
Authorization rules may apply. | |||||
10% of the cost for Medicare-covered items. | |||||
Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies | |||||
$0 copay for Diabetes self-monitoring training. | |||||
$0 copay for Nutrition Therapy for Diabetes. | |||||
5% to 25% of the cost for Diabetes supplies. | |||||
Separate Office Visit cost sharing of $15 may apply. | |||||
** Preventive Services ** | |||||
Bone Mass Measurement | |||||
$0 copay for Medicare-covered bone mass measurement | |||||
Separate Office Visit cost sharing of $15 may apply. | |||||
Colorectal Screening Exams | |||||
$0 copay for
| |||||
Separate Office Visit cost sharing of $15 may apply. | |||||
Immunizations | |||||
$0 copay for Flu and Pneumonia vaccines. | |||||
$0 copay for Hepatitis B vaccine. | |||||
No referral needed for Flu and pneumonia vaccines. | |||||
Pap Smears and Pelvic Exams | |||||
$0 copay for Medicare-covered pap smears and pelvic exams | |||||
Separate Office Visit cost sharing of $15 may apply. | |||||
Prostate Cancer Screening Exams | |||||
$0 copay for
| |||||
Separate Office Visit cost sharing of $15 may apply. | |||||
** Additional Benefits ** | |||||
Dialysis | |||||
$0 copay for renal dialysis | |||||
$0 copay for Nutrition Therapy for End-Stage Renal Disease | |||||
Prescription Drugs | |||||
Most drugs not covered. | |||||
$0 copay for Part B-covered drugs. | |||||
This plan does not offer prescription drug coverage. | |||||
Dental Services | |||||
In general preventive dental benefits (such as cleaning) not covered. | |||||
$15 copay for Medicare-covered dental benefits. | |||||
Hearing Services | |||||
Hearing aids not covered. | |||||
$0 copay for Medicare-covered diagnostic hearing exams | |||||
Vision Services | |||||
$0 copay for
| |||||
$300 plan coverage limit for eye wear every year. | |||||
Plan offers additional vision benefits. | |||||
Physical Exams | |||||
$0 copay for routine exams. | |||||
Limited to 1 exam(s) every year. | |||||
Separate Office Visit cost sharing of $15 may apply. | |||||
Health/Wellness Education | |||||
The plan covers the following health/wellness education benefits: | |||||
$0 copay for each Medicare-covered smoking cessation counseling session. | |||||
$0 copay for each Medicare-covered HIV screening. | |||||
HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. | |||||
Transportation | |||||
This plan does not cover routine transportation. | |||||
Acupuncture | |||||
This plan does not cover Acupuncture. |